Throughout the United States, patients are using the ED for the treatment of acute but minor episodic conditions. According to Truven Health Analytics, 42% of ED visits are for urgencies that could be treated in the primary care office setting. Even as more urgent care centers are being opened, this problem persists. In some cases, ED care is sought because a patient’s primary care physician (PCP) office operates mostly within normal daytime business hours. Other times, it may be because of difficulty in obtaining same day appointments. There are simple changes PCPs can make to help patients avoid ending up in the ED for these types of conditions. The Greater Detroit Area Health Council (GDAHC) ED Utilization Team leads the effort in Detroit. In my work as chair of the GDAHC team—which includes representation from EDs, PCPs, purchasers, health plans and consumers—we piloted an initiative with 11 PCPs at five practice sites to give patients better options when faced with acute, unscheduled medical needs. Sites were chosen because they had a worsening trend of their HMO members using the ED for conditions likely treatable in the PCP office. Collectively, these PCPs reduced these types of ED visits from 49.2 to 7.3 visits per 1,000 members. Here are some of the key lessons from our program: Collaborate The goal is to get everyone in the PCP office working together in the same direction. The first step is to establish an access-to-care policy. Everyone from receptionists to nurses to physicians needs to understand what access to care means and define it together. This includes how to handle clinical advice for patients...

Abscesses are one of the most common skin conditions encountered by general practitioners and emergency physicians, and the incidence of these infections has increased in recent years. In addition, MRSA infections have become one of the most common causes of skin abscesses. “Community-associated MRSA (CA-MRSA) has also been shown to cause severe infections in non-immuno-compromised hosts,” explains David A. Talan, MD, FACEP, FIDSA. “We’re still unsure as to why CA-MRSA appears to be more virulent than other healthcare–associated strains and methicillin-susceptible Staphylo-coccus aureus. Unfortunately, the management of skin abscesses is highly variable throughout the country.” In a review article published in the New England Journal of Medicine, Dr. Talan and Adam J. Singer, MD, described helpful approaches to managing common skin abscesses that generally involve the extremities and trunk. “When possible, our recommendations were based on randomized trials,” Dr. Talan says. “However, many recommendations are based on small observational studies or expert opinion. While there may be some disagreement, the approaches we advise have been both workable and useful in our practice.” Diagnosis Skin abscesses typically appear as a swollen, red, tender, and fluctuant mass, often with surrounding cellulitis. The diagnosis of skin abscesses based on physical exams is often straightforward and proven correct by incision and drainage. Ultrasonography may be helpful for cases in which the abscess is deep, complex, or obscured by extensive cellulitis. It may also be helpful for patients treated for cellulitis in which initial antibiotic treatment fails and to ensure the adequacy of drainage. Needle aspiration is an alternative approach to diagnosing and treating abscesses. Treatments “Standard incision and drainage is the mainstay of...

There seems to be no shortage of bad doctor stories going around these days. Just when you thought you’d heard the worst, along comes another. Dr. Ehab Mohamed, a “cosmetic surgeon” in California, has lost his license to practice medicine and has been charged with involuntary manslaughter in the 2010 death of a 61-year-old woman during a 10-hour liposuction procedure performed in his office. She apparently died from an overdose of lidocaine, fentanyl, and oxycodone. This physician may have trained at renowned institutions. One website says the doctor had been a resident at both Columbia and Johns Hopkins. However, this cannot be verified. His training was in obstetrics and gynecology, and he was not board-certified. He called himself a cosmetic surgeon but apparently had no formal training in cosmetic or plastic surgery. In addition to the manslaughter charge, he was charged with elder abuse of a 77-year-old woman who also had complications during liposuction. He charged patients exorbitant fees for procedures, allegedly as high as $650,000, but routinely in the range of $50,00 to $100,000. He once anesthetized a patient for surgery, and while she was sedated, apparently had her sign for more surgery at an increased fee. He supposedly offered discounts to patients if they would enroll in a Harvard University study, which was later proven to be fake by Charles Feldman, a persistent investigative reporter for a Los Angeles radio station. The California Medical Board was warned by other surgeons about him 2 years before the death of the liposuction patient. He has also apparently been living illegally in the United States since his visa expired in...

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